Dealing with Difficult Physicians and Thorny Query Situations

2. Dealing with Difficult Physicians and Thorny Query Situations Pamela P. Bensen, MD, MS, FACEP

3. Pamela P. Bensen, MD, MS, FACEP Drexel University Medical College of PA, 1971 Dartmouth Medical School, MS Quality, 1997 38 years of emergency medicine practice 3 decades as physician documentation educator APC, CDI, CPT, DRG, EMTALA, HIPPA, ICD-9-CM, risk management, severity of illness, pay for performance

4. Goals • Improve skills for dealing with difficult physicians • Look at problematic clinical situations • Discuss effective methods for clarifying documentation • Compare best practices for working with reluctant physicians

5. Front of white card • Describe your most difficult physician Back of white card • Describe CDI education that physician received before you interacted with him/her • Duration • Venue • Teacher • Reminders Describe a problematic clinical situation Describe an effective method for clarifying documentation Describe a best practice for working with reluctant physicians Your contact information, if you do not have a business card

6. Pre-test • True False • True False • True False • True False The most difficult part of CDI is dealing with difficult physicians Problematic clinical situations challenge effective methods for clarifying documentation Best practices force reluctant physicians to participate in CDI Physicians know clinical documentation

7. Standard Query RE: Mr. Smith Dear Dr. X, I noted: on (date), in (location), the following clinical indicators … When documented by the physician, these findings often contribute to a patient’s severity of illness (SOI). … Please provide additional documentation in your progress notes and discharge summary. Thank you, Pamela P. Bensen, CDS Ext: 521

8. Anemia • 77 yo m weak & dizzy, fell at home • S: PMH rectal polyp, can’t remember if pathology • O: Pale, P 120, R 28, BP 90/60 • A: H&H • P: 2 units packed RBC, sigmoidoscopy • Query • Please be more specific about the H&H and diagnosis • Physician thought process • 8/24, it’s right on the chart • I don’t know yet, that is why I ordered the sigmoidoscopy

9. Physician Response • Ignores query, never answers question

10. Anemia • Not enough healthy red blood cells (RBC) • Gold Standard • Hemoglobin • Hematocrit • Normal • Variable by age, gender, race • Men 14 to 18 g/dl 40%–54% • Female 12 to 16 g/dl 36%–48% http://www.ncbi.nih.gov/books/NB259

11. Anemia • “Normal” for elderly, sick, pregnant, cancer • Serious if severe or acute • Multiple guidelines • Treatment guidelines, 55% adherence • Usually no abbreviations • Surgical complication http://www.asco.org/ascov2/Meetings/Abstracts?&vmview=abst_detail_view&confID=47&abstractID=35129

12. What Is the Job of CDS? • CFO – improve case-mix index (CMI) • HIM – ensure codeable documentation • Physicians – capture severity of illness (SOI) • Know clinical indicators • Know your physician • Take time to know what's up with the “doc” • Can’t leave this to someone else • Ask others what works

13. Physician Education, Growth & Development • Medical school • 20 to 24 years old • 4 years (14,000 hours) • Residency & fellowship • 3–8 years (15–40,000 hrs) • Documentation not valued • No training in • ICD-9-CM, DRGs, RW, SOI, LOS, ROM, CMI • Coding process, rules, language • CDI documentation • CDI • Medical advisor training • 20 hours • 8 hours • 4 hours • Specially scheduled CME meeting • 1–1 ½ hours • Medical staff or department meeting • 1 hour • 20 minute • 5 minutes

14. Analyze Physician Behavior • Isolated incident • Seek to understand “why now” • Didn’t see the query • Distracted by other issue(s) • New • Periodic • Is patient unique? • New clinical problem for this physician • Follow-up in person > query

15. Analyze Physician Behavior • Consistent pattern • Disease related • How did you phrase your question? • Is physician comfortable with disease definitions? • Is it efficient to accurately document this disease?

16. Analyze Physician Behavior • Basic data for physician trended over time • Spreadsheet or binder • Patient profile • ICD-9-CM • DRG • CMI • By ICD-9-CM • Similar physician comparison • Length of stay (LOS) • By ICD-9-CM • Similar physician comparison • Query response • By ICD-9-CM • Rapidity & type

17. Audience Question • Which of you started a CDI program and then moved to a different, established program? • What was your biggest challenge? • What did you do about it?

18. Effective Solutions • Query • …Please name the disease represented by your note “A: H&H” • I have attached a newsletter to explain why we need you to document a disease rather than a test result • Educate • Provide a one-page newsletter explaining basic CDI rules about coding requirements for explicit physician documentation

19. Effective Solutions • Query • …I realize you do not know what is causing the decrease in H&H, but would you please document what you suspect (are looking for) which resulted in the order for a sigmoidoscopy? • Don’t try to do it all at once • Although you could provide a one-page newsletter explaining basic CDI rules about uncertainty, select the one most important issue to focus on in this query

20. Effective Solutions • Documentation newsletters • Anemia • Test results • Uncertainty • New approved abbreviations • ABLA • PDH • Poster/screen saver types of anemia • EMR pull-down list modifications • Remove “low hemoglobin” • Add new abbreviations • Add types of anemia

21. Effective Solutions – Education • Document type of anemia at least once • Not “HCT,” “HCT 20” • Can’t code from lab result • Hard to determine which of > 400 types of anemia • Acquired hemolytic • Aplastic • Blood loss • Chronic disease • Folic acid deficiency • Iron deficiency • Dietary • Chronic blood loss • Pernicious (B12 deficiency) • Pure RBC aplastic • Sickle-cell (Is patient in crisis?) • Blood loss • Occult/internal • Acute, chronic, acute on chronic • From where? • Expected due to … GI bleed, Fx hip/pelvis, DUB, chemotherapy • Surgical complication • 285.1 = HealthGrades complication • Surgeons unwilling to document “acute blood loss anemia” • 790.01 = Alternative – “Precipitous drop in HCT” (20%)

22. Pneumonia • 87 yof NH resident fever & chills x 1 week • S: Cough, failed outpatient antibiotics • A: T 98 P 100, R 18, Rales r base, CXR neg, WBC 10 • O: HAP • P: Clindamycin 600 mg IV bid, swallow precautions • Query • …Please indicate what caused this patient’s pneumonia • Physician thought process • I followed the pneumonia guidelines • How do I know what caused it? • Sputum culture was negative • Blood culture was negative

23. Physician Response • Argue to the end

24. Pneumonia • Infection or inflammation of alveoli of the lungs • No Gold Standard • No way to know for sure whether it is pneumonia • CXR inaccurate initially, in dehydration, in fluid overload • CT more precise detail • No way to know for sure what caused it • Sputum Gram’s stain & C&S • Not required for diagnosis • Often normal due to outpatient antibiotics • Blood culture rarely positive • Pneumococcal/Legionella urine antigen testing (UAT) • Guidelines improve chance treatment will be effective

25. Pneumonia • Documentation needed from physician • Diagnosis of pneumonia • If not pneumonia, what is wrong with the patient? • Cause of pneumonia • Suspected infectious agent treated • Cause of inflammation • Facility guidelines foster “CAP,” “HAP,” “VAP” • Modify to include likely organisms • Need to be updated annually with local antibiogram • What medication works on what organism

26. Analyze Physician Behavior • Not isolated • Not disease related • Basic data • Amount of CDI education physician has received • Apparent understanding of CDI and SOI • Knowledge of definitions

27. Effective Solutions • Query • …Thank you for using the pneumonia order sheet for this patient. I realize the cultures were negative, but would you please use the attached antibiogram from the lab as a reference to help you document which “suspected” organism necessitated Clindamycin? • Educate • Provide a one-page newsletter explaining documentation of uncertainty in determining the cause of pneumonia

28. Effective Solutions • Annual antibiogram • Newsletters • Uncertainty is medically acceptable • Differential diagnosis includes likely possibilities • Treatment is started without diagnosis • Sometimes no diagnosis is determined • Coding (CMS) • “If the diagnosis documented at the time of discharge from an inpatient admission is qualified as ‘probable,’ ‘suspected,’ ‘likely,’ ‘possible,’ or ‘still to be ruled out,’ code the condition as if it existed or was established.” • An uncertain diagnosis is not acceptable for outpatient diagnoses Official Guideline for Coding and Reporting Section II, H. (Uncertain Diagnosis). Selection of principal diagnosis 12/1/2005 Coding Clinic, First Quarter 2006, pp. 99–101.

29. Effective Solutions Physician Response • “I don’t know what is wrong with the patient!” • “There is no Gold Standard diagnostic test to confirm my suspicions.” • “The test was negative.” • “Tell me what you are treating.” • “Tell me what you think is wrong with the patient.” • “Confirmation” does not require documentation of positive laboratory testing.” Official Guideline for Coding and Reporting Chapter 8: Respiratory system diseases coding guidelines 10/01/2008 Coding Clinic, Fourth Quarter 2009, p. 158.

30. Effective Solutions • Physician needs basic CDI education • Only physician who needs it • Make an appointment with the office • ICD-9-CM problems affect offices too • One-on-one time • Provide lunch • 45-minute education program presented by medical advisor • If others also need it • CME program about CDI and SOI • CME programs on diseases which present a problem

31. Audience Questions • Who has less than 5 difficult physicians? • Who considers more than 80% of the medical staff a problem?

32. Heart Failure 78 yof SOB • S: Always sl SOB, worse last night, sl chest pain, ran out of meds last week, PMH: MI 3 mos ago, 2 stents, EF 35% • O: R 22, P 100 BP 170/110 Rales both bases, +2 pedal edema • A: CHF, evaluate for stent blockage • P: Lasix, fluid restriction, beta blocker, cath • Query …Please indicate the acuity and type of heart failure • Physician thought process • I was treating it; if she took her meds, this wouldn’t have happened. • She got worse last night, obviously it is acute on chronic. • I already said “congestive” heart failure, what more do they want? • Why don’t they leave me alone.

33. Physician Response • Gets emotional (angry, hostile, frustrated)

34. Heart Failure Systolic? Diastolic?

35. Heart Failure Normal Diastolic Systolic Diastole Systole For a demonstration on how the heart works, please see: http://www.nhlbi.nih.gov/health/dci/Diseases/hhw/hhw_pumping.html

36. Heart Failure

37. Heart Failure • 1990s, identified systolic & diastolic HF by echocardiogram • Physicians trained before 1990 know nothing about it • Often doesn’t change treatment • Diuretics • Angiotensin-converting enzyme (ACE) inhibitors • Beta blockers • Angiotensin II receptor blockers (ARB) • Diastolic HF – ventricle cannot fill • Systolic HF – ventricle cannot contract, EF < 35% • Echo • Not done • Record not available

38. Dealing with a Difficult Physician • You cannot go it alone • Facilitywide program • Backed by administration • Supported by physician leaders • Accepted by medical staff • Establish • Role of medical advisor • Zero tolerance for responding to queries • Coordinated team effort individualized for a single physician • Process for difficult physician interventions • Find mentor(s)

39. Mentoring • Who would like a CDI mentor? • Pass your business card, or an index card with your contact information on it, to the end of the row. • Pick up a card as you leave. • Make sure you don’t know the person. • Initially without electronics, try to find the person.

40. Analyze Physician Behavior • Not isolated +/- disease related • Basic data • Amount of CDI education physician has received • Apparent understanding of CDI and SOI • Knowledge of definitions • Review previous query responses • Fear is basis of emotional responses • Loss of independence • Ignorance exposure • Medical capability being questioned • Fraud • Level of reluctance, resistance, defiance • Delayed growth and development

41. Effective Solutions • Need to meet angry physicians face-to-face, with privacy • Be prepared in advance … as in NOW • Realize the anger is not personal • Plan not to win battle, working for the long run • Determine what they fear • Exposure of ignorance • Loss of independence • Other repercussions (fraud, economic)

42. Effective Solutions • Countermeasures • Validate it is OK not to know CDI • CDS is the messenger sent to help • Acuity is easy to learn, easy to document • Educational material about heart failure • Peer-reviewed scientific articles • CDI newsletter • Offer physician mentors

43. How to Respond • “Do you get more money if I write this?” • Smile, slow shake of the head, “No, but you and the hospital get what you have earned for taking care of this patient.” • “What difference does it make if I write this rather than that?” • “You will have painted a clearer picture of how sick your patient really is.” • “Won’t this be considered a complication?” • “Undoubtedly someone will try to make you think it is a complication, that is where the CDI team comes in, helping you to write it accurately.” • “How does this affect me?” (What’s in it for me?) • “You will have represented your patient accurately.”

44. How to Respond • “I have no idea.” • “Can you express that by explaining what you suspect or think is possible? What you are treating and testing for?” • “I never add addendums; it looks suspicious.” • “A dated and signed addendum is the accepted and appropriate way to update a medical record.” • “I can’t document that without a positive culture/finding, etc.” • “In many cases, a definitive diagnosis will never be made. There is no test with 100% sensitivity and 100% specificity.”

45. Effective Solutions • Query • …I realize it is medically obvious from the history, but to capture the accurate severity of illness of this patient we need to have you explicitly document whether the heart failure is chronic, acute, or acute on chronic and whether it is systolic, diastolic, or both. • I have attached a the summary of heart failure we distributed to the medical staff at … • Educate • Provide a one-page newsletter explaining heart failure from a CDI perspective

46. Effective Solutions • Emotional response to polite, appropriate queries require resolution by acknowledgment that: • CDI • Has the obligation per facility policy • To request, from every physician, additional documentation to facilitate accurate capture of severity of illness • To supply physician with • Clinical indicators • Medical references • CDI and coding references • CDI education • Physician • Has the obligation to respond to all queries • Has the right to disagree with CDI clinical analysis • Is the last word

47. Effective Solutions • CMS and The Joint Commission • Providers are: • Expected to provide legible, complete, clear, consistent, precise, and reliable documentation of the patient’s health history, present illness, and course of treatment. • Include observations, evidence of medical decision-making in determining a diagnosis, and treatment plan, as well as the outcomes of all tests, procedures, and treatments. • Be as complete and specific as possible, including information such as the level of severity, specificity of anatomical sites involved, and etiologies of symptoms.

48. Effective Solutions • CMS FY 2008 Final Rule: • “We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.”

49. Effective Solutions • ICD-9-CM Official Guidelines for Coding and Reporting • A joint effort between the healthcare provider and the coding professional is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. • The importance of consistent, complete documentation in the medical record cannot be overemphasized. • Without such documentation, accurate coding cannot be achieved. • The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. • Lack of accurate and complete documentation can result in the use of nonspecific and general codes, which can impact data integrity, reimbursement, and present potential compliance risks.

50. Effective Solutions • Office of Inspector General (OIG) • “Fraud” is “reckless disregard” or “deliberate ignorance” of the rules. • If coders have a pattern of not clarifying records that result in “abusive” overpayments, then intent to deceive can be presumed.